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PEDIATRIC NURSING I. A. GROWTH AND DEVELOPMENT Definition of Terms: Growth – increase in physical size of a structure or whole quantitative structure 2 Parameters of Growth 1. Weight - Most sensitive especially in low birth weight - Weight doubles by 6 months - Triples by 1 year - Quadruples by 2 ½ year 2. Height - Increase by 1 inch per month during first 6 months - And ½ inch per month from 7 – 12 months Development – increase in the skills or capacity to function qualitative change How to Measure Development? 1. by simply observing a child doing specific task 2. by noting parent’s description of the child’s progress 3. by DDST (Denver Developmental Screening Test), MMDST (Metro Manila Developmental Screening Test) 4 Main Rated Categories 1. Language – for communication 2. Personal Social 3. Fine Motor Adaptive – pre tensile ability (ability to use hand movement) 4. Gross Motor Skills – ability to use large body movement Maturation – synonymous with development (readiness) Cognitive Development – is the ability to learn and understand from experience, to acquire and retain knowledge to respond to a new situation and to solve problems I. B. BASIC DIVISION OF LIFE 1. Pre-Natal – begins at conception and ends at birth 2. Period of Infancy - Neonatal (first 28 days or first 4 weeks) - Formal Infancy (from 29th day to 1 year) 3. Early Childhood - Toddler (1 – 3 years) - Pre-School (4 – 6 years) 4. Middle Childhood – school age 7 – 12 years 5. Period of Adolescent - Pre-Adolescent/Late childhood (11 – 13 years) - Adolescent (12 – 21 years) I. C. PRINCIPLE OF GROWTH AND DEVELOPMENT 1. Growth and Development is a continuous process that begins from conception and ends with death. Principle: womb to tomb 2. Not all parts of the body grow at the same time or at the same rate. Patterns of Growth and Development 1. Renal, digestive, circulatory, Musculo-skeletal (childhood) 2. Neurologic Tissue - Grows rapidly during 1 – 2 years of life - Brain (achieve to its adult proportion by 5 years) - Central Nervous System - SC 3. Lymphatic System - Lymph nodes, Spleen, Thymus - Grows rapidly during infancy and childhood (to provide protection against infxn) - Tonsils is achieved in 5 years 4. Reproductive Organ – grows rapidly during puberty 3. Each child is unique 2 Primary factors affecting Growth and Development A. Heredity Race Intelligence Sex Nationality B. Environment Quality of nutrition Socio-Economic status Health Ordinal position in family Parent-Child relationship 4. Growth and Development occurs in a regular direction reflecting a definite and predictable patterns or trends A. Directional Trends – occurs in a regular direction reflecting the development of neuromuscular functions: these apply to physical, mental, social and emotional developments and includes: a. Cephalo - caudal (head to tail) - It occurs along bodies’ long axis in which control over head, mouth and eye movements and precedes control over upper body torso and legs. b. Proximo – distal (centro distal) - Progressing from the center of the body to the extremeties c. Symmetrical - Each side of the body develop on the same direction at the same time at the same rate d. Mass – specific (differentiation) - In which the child learns from simple operations before complex function or move from a broad general pattern of behavior to a more refined pattern. B. Sequential – involves a predictable sequence of growth and development to which the child normally passes. a. Locomotion b. Language and Social skills C. Secular – refers to the worldwide trend of maturing earlier and growing larger as compared to succeeding generations. 5. Behavior is a most comprehensive indicator of developmental status 6. Play is the universal language of a child 7. A great deal of skill and behavior is leaned by practice 8. There is an optimum time for initiation of experience or learning 9. Neonatal reflexes must be lost first before development can proceed Persistent Primitive Infantile Reflex (suspect Cerebral Palsy) I. D. THEORIES OF DEVELOPMENT Development Tasks is a skill or growth responsibility arising at a particular time in the individual’s life. The successful achievement of which will provide a foundation for the accomplishments of the future tasks. THEORISTS 1. Sigmund Freud (1856-1939) – an Austrian neurologist, Founder of psychoanalysis PHASE OF PSYCHOSEXUAL THEORY a. Oral Phase (0 – 18 months) - Mouth is the site of gratification - Biting, crying or sucking for enjoyment and to release tension - Provide oral stimulation even the baby is NPO, offer pacifier - Never discourage thumb sucking b. Anal Phase (18 months – 3 years) - Anus - May show toilet training - Elimination, defecation - Principle of - Holding on (child wins, hard headed, anti social and stubborn) - Letting Go - Mother wins (kind, perfectionist, obedient, obsessive – compulsive) c. Phallic Phase (4 – 6 years) - Genitals - May show exhibitionism - Accept the child fondling his own genital area as the normal area of exploration - Answer the child’s question early d. Latent Phase (7 – 12 years) - Period of suppression - Because there is no obvious development - Child’s energy or libido is diverted to more concrete type of thinking - Help child achieve positive experiences e. Genital Phase (12 – 18 years) - Achieved sexual maturity - Learn to establish satisfactory relationship with opposite sex - Give an opportunity to relate with opposite sex 2. Eric Erickson - Trained in psychoanalysis theory - Transits the importance of culture and society to their development of ones society STAGES OF PSYCHOSOCIAL THEORY Trust vs. Mistrust (0 – 18 months) - Trust is the foundation of all psychosocial task - To give and to receive is the psychosocial theme - How trust is developed: - Satisfy needs on time - Care must be consistent and adequate - Give and experience that will add to security (touch, hugs and kisses, eye to eye contact, soft music Autonomy vs. Shame and Doubt (18 months – 3 years) - Autonomy is independence or self governance - How autonomy is developed - Give an opportunity for decision making such as offering choices - Encourage the child to make decisions rather than judge Initiative vs. Guilt (4 – 6 years) - Learns to do basic things - Activity recommended are modeling clay, finger painting - Develop creativity and imagination to facilitate fine motor development - How initiative is developed: - Give an opportunity of exploring new places and events Industry vs. Inferiority (7 – 12 years) - Learn how to do things well - How industry is developed: - Give an opportunity no short assignment and projects Identity vs. Role Confusion (12 – 20 years) - Learn how he/she is or what kind of person he/she will become by adjusting to new body image - Seeking emancipation or freedom from parents Intimacy vs. Isolation (20 – 40 years) - Focus on career or looking for lifetime partners Generativity vs. Stagnation (40 – 60 years) Ego Integrity vs. Despair (65 and above) 3. Jean Piaget – a Swiss psychologist STAGES OF COGNITIVE DEVELOPMENT A. Sensorimotor (0 – 2 years) - Practical intelligence because words and symbols are not applicable - Babies are communicating through sense and reflex SCHEMA AGE BEHAVIOR Neonatal Reflex 1 month - All reflexes Primary Circular Reaction 1 – 4 months - Activities related to bodies repetition of behavior (thumb sucking) Secondary Circular Reaction 4 – 8 months - Activity not related to body - Discover object or persons code and code memory arises - Anticipate familiar events Coordination of Secondary 8 – 12 months - Exhibit goal directed behavior - Increase sense of separateness Tertiary Circular Reaction 12 – 18 months (1 – 1 ½ year) - Use trial and error to discover change of places and events - Code and Code invention of new means - Capable of space and time perception Invention of new means thru 18 – 24 months - Transitional phase to operational mental combination period B. Preoperational Thought 2 – 7 years old SCHEMA AGE BEHAVIOR Pre-conceptual 2- 4 years - Egocentric (unable to view another point of view) - Their thinking is basically concrete and static - Their concept of time is only now and their concept of distance is only as far as they can see Intuitive 4 – 7 years - Not yet aware of the concept of reversibility - Concept of animism (inanimate object is alive) C. Concrete Operational (7 – 12 years) - Can find solutions to everyday problems with systemic reasoning - They have concept of reversibility - Activity recommended is collecting and classifying D. Formal Operational (12 and above) - Period when cognition has achieved its final form - They are capable - Can find scientific reasoning (can deal with the past, present and future) - Capable of abstract and mature thought - Do abstraction by talk time that will sort 4. Kohlberg (1984) – recognized the theory of moral development as considered closely to approximate cognitive stages of development STAGES OF MORAL DEVELOPMENT INFANCY Age (Year) Description Preconventional Stage 2-3 (Level I) 1 Punishment/obedience orientation (“heteronomous morality”). Child does right because a parent tells him/her to and to avoid punishment. 4-7 2 Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs rather than society. Will do something for another if that person do something for the child Conventional (Level II) 7-10 3 Orientation to interpersonal relations of mutuality. Child follows rules because of a need to be a “good” person in own eyes and the eyes of 10-2 4 others. Maintenance of social order, fixed rules and authority. Childs finds following rules satisfying. Follows rules of Authority figures as well as parents in an effort to keep the “system” working Postconventional (Level III) Older than 12 5 Social contract, utilitarian law-making perspectives. Follows standards of society for the good of all people 6 Universal ethical Principle orientation. Follows internalized standards of conduct. I. E. DEVELOPMENTAL MILESTONE PERIOD OF INFANCY a. Play - Solitary play - Non interactive - Priority is safety - Age who appreciate teddy bears - Attitude: proper hygiene b. Fear - Stranger anxiety - Begin at 6 – 7 months - Peak at 8 months - Diminish by 9 months c. Milestones E.I Neonate - Largely reflex - Complete head lag - Hands fisted - Cry without tears (due to immature larcrimal duct) - Visual fixation of human face 1 MONTH - Dance reflex disappears - Looks at mobile objects 2 MONTHS - Holds head up when in prone - Social smile - Baby “coos” - Cry with tears - Closure of posterior fontanel by 2 – 3 months - Head lag when pulled to a sitting position 3 MONTHS - Holds head and chest when in prone - Follow object past midline - Grasp and tonic neck reflex are fading - Hand regards (3 months) 4 MONTHS - Turns from front to back - Head control complete - Bubbling sounds - Needs space to turn - Laugh aloud 5 MONTHS - Roll over - Turn both ways - Teething rings - Handles rattle well - Moro reflex disappear by 4 – 5 months 6 MONTHS - Reaches outs in anticipation of being picked up - Handle bottle well - Sits with support - Uses palmar grasp by 6 months - Eruption of first temporary teeth (2 lower incisors) - Says vowel sounds “Ah, ah” 7 MONTHS - Transfer objects hand to hand - Beginning fear of stranger - Likes objects that are good sized 8 MONTHS - Sits with support - Peak of stranger anxiety - Plantar reflex disappear 9 MONTHS - Creeps/crawl - Needs space for creeping - Pincer grasp reflex - Combine two syllables “Papa, Mama” - Priority: safety 10 MONTHS - Pull self to stand - Understand word “No” - Respond to own name - Peak – a – boo - Pat a cake since they can clap 11 MONTHS - Cruises - Stand with assistance 12 MONTHS - Stand alone - Take first step - Walk with assistance - Drink from a cup - Cooperate in dressing - Says the 2 words “Mama, Papa” - Toys: pots and pans, pull toy and learn nursery rhymes E.2. TODDLER a. Play - Parallel (2 toddlers playing separately) - Provide two similar toys (squawky squeeze toy) - Waddling duck to pull, pull truck, building block and pounding peg b. Fear - Separation anxiety - Do not prolong goodbye, say goodbye firmly - 3 Phases of separation anxiety a. Protest b. Despair c. Denial c. Milestones 15 months - Plateau stage - Walks alone (delay in walking maybe a sign of mental retardation) - Puts small pellets into small bottle - Scribbles voluntarily with pencil - Holds a spoon well - Seat self on chair - Creep upstairs - Speaks 4 – 6 words 18 months - Hide of possessiveness - Bowel control achieved - No longer rotates a spoon - Run and jump in place - Walk up and down stairs holding on (typically places both feet on one step before advancing) - Able to name body part - Speaks 7 – 20 words 24 months - Can open doors by turning doorknobs - Unscrew lids - Walk upstairs alone by still using both feet on the same step at same time - Daytime bladder control - Speak 50 – 200 words 30 months - 3 year old do tooth brushing with little supervision - 2 – 3 year old is the right time to bring to the dentist - Temporary teeth complete and last temporary teeth to appear is the posterior molars - 20 deciduous teeth by age 2 ½ years - Can make simple lines or stroke for crosses with a pencil - Can jump down from the stairs - Knows full name - Copy a circle - Holds up fingers 36 months - Trusting three - Able to unbutton - Draw a cross - Learns how to share - Full name and sex - speak fluently - Right time for bladder control (night time control) - Able to ride a tricycle - Speak 300 – 400 words - Clues for toilet training a. Can stand, squat and walk alone b. Can communicate toilet needs c. Can maintain himself dry with interval of 2 hours d. Character Traits - Negativistic likes to say no (it is their way to search independence) - Limit questions and offer options - Temper tantrums (stomping feet and screaming) - Ignore the behavior - Rigid ritualistic: stereotype - Cause: mastering - Protruded abdomen - Cause: - Under development of abdomen - Unsteady gait - Physiologic anorexia (give foods that last for a short period of time) E.3. PRE-SCHOOL a. Play - Associative play, Cooperative play - Play house - Role playing b. Fear - Body mutilation or castration fear - Dark places and witches - Thunder and lighting c. Milestone 4 years - Furious four (noisy and aggressive) - Able to button - Copy a square - Lace shoes - Know the 4 basic colors - Vocabulary of 1500 words 5 years - Frustrating five - Copy a triangle - Draw a 6 part - Imaginary playmates - 2100 words d. Character Traits - Curious - Creative - Imaginative - Imitative - Why and How e. Behavior Problems - Telling tall tales (over imagination) - Imaginary friends (purpose: release their anxiety and tension) - Sibling rivalry (jealousy to a newly delivered baby) - Bed wetting - Baby talk - Fetal position - Masturbation is a sign of boredom and should divert their attention E.4. SCHOOL AGE (7 YEARS) a. Play - Competitive play - Tug – o – war b. Fear - School phobia - To prevent phobia orient child to new environment - Displacement from school - Significant person is the teacher and peer of the same sex - Loss of privacy - Fear of death c. Significant Development - Prone to bone fracture (green stick fracture) - Mature vision d. Milestones 6 years - Temporary teeth begins to fall - Permanent teeth begins to appear (first molar) - Year of constant motion - Clumsy movement - Recognizes all shapes - Teacher becomes authority figure that may result to nail biting - Beginning interest with God 7 years - Age of assimilation - Copy a diamond - Enjoys teasing and play alone - Quieting down period 8 years - Expansive age - Smoother movement - Normal homosexual - Love to collect objects - Count backwards 9 years - Coordination improves - Tells time correctly - Hero worship - Stealing and lying are common - Takes care of body needs completely - Teacher find this group difficult to handle 10 years - Age of special talents - Writes legibly - Ready for competitive sports - More considerate and cooperative - Joins organization - Well mannered with adults - Critical of adults 11-12 years - Pre adolescent - Full of energy and constantly active - Secret language are common - Share with friends about their secrets - Sense of humor present - Social and cooperative e. Character Traits - Industrious - Love to collect objects - Cant bear to loose they will cheat - They are modest SIGNS OF SEXUAL MATURITY Girls Boys Increase size of breast and genetalia Appearance of axillary and pubic hair Widening of hips Deepening of voice Appearance of axillary and pubic hair Development of muscles Menarch (last sign) Increase in size of testes and scrotum (1st sign) - telarch is the 1st sign of sexual maturity Production of viable sperm (last sign) E.5. ADOLESCENT PERIOD - They have distinctive odor because of the stimulation of apocrine gland - They have nocturnal emission (wet dreams) the hallmark for adolescent - Testes and scrotum increase in size until age 17 - Sperm also viable - Breast and female genetalia increase until age 18 a. Fear - Acne - Obesity - Homosexuality - Death - Replacement from friends b. Significant Person - Peer of opposite sex c. Significant Development - Experiences conflict between his needs for sexual satisfaction and societies expectations - Core concern is change of body image and acceptance from the opposite sex d. Personality Trait - Idealistic (parent-child conflict begins) - Rebellious - Very conscious with body image - Reformer - Adventuresome e. Problems - Vehicular accident - Smoking - Alcoholism - Drug addiction - Pre marital sex IMMEDIATE CARE OF THE NEWBORN A. THE 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAY OF LIFE 1. Initiation and Maintenance of respiration 2. Establishment of extra uterine circulation 3. Control of body temperature 4. Intake of adequate nourishment 5. Establishment of waste elimination 6. Prevention of infection 7. Establishment of an infant-parent relationship 8. Development care that balances rest and stimulation for mental development 1. Initiation and Maintenance of respiration Alerts - Second stage of labor initiate airway - Initiation of airway is a crucial adjustment among newborn - Most neonatal deaths with in the first 24 – 48 hours is primarily the inability to initiate airway - Lung function begins only after birth How A. Removal of secretions by proper suctioning B. Proper Suctioning of catheter - Place baby’s head to side to facilitate drainage - Suction nose first because neonates are nasal obligates - Suction for 5 – 10 seconds and should be gentle and quick because prolong deep suctioning may result to hypoxia, bradycardia (caused by vagal nerve stimulation) and laryngospasm C. If not effective, requires effective laryngoscopy to open the airway. After deep suctioning, an endotracheal tube can be inserted and oxygen can be administered by a positive pressure bag and mask with 100% oxygen at 40 – 60 b/min. Nursing Alerts: - No smoking sign to prevent combustion - Always humidify to prevent drying of mucosa - Mask should cover nose and mouth - Overdosage of oxygen may lead to scaring of retina which may lead to blindness called RETROLENTAL FIBROPLASIAS (retinopathy of prematurity) - When meconium stained never administer oxygen because pressure will force meconium to the alveolar sac and cause atelectasis 2. Establishing extrauterine circulation Alerts: circulation is initiated by pulmonary ventilation and is completed by cutting of cord THE FETO-PLACENTAL CIRCULATION Placenta (via simple diffusion) – oxygenated blood is carried by the vein – liver – Ductus venosus Inferior vena cava – right atrium – 70% shunted to Foramen ovale - left atrium – mitral valve – left ventricle – aorta – lower extremities. The remaining 30% - tricuspid valve – right ventricle – pulmonary artery – lungs (for nutrition) – vasoconstriction of the lungs pushes the blood to the Ductus arteriosus to aorta to supply the extremities. The two arteries carry the unoxygenated blood back to the placenta for reoxygenation. Alerts: Increase pressure on the left side of heart causes closure of foramen ovale SHUNTS 1. Ductus Venosus – shunt from umbilical vein to inferior vena cava 2. Foramen Ovale – shunt between 2 atria (begin to close within 24 hours) 3. Ductus Arteriosus – shunt from pulmonary artery to aorta (begin to close within 24 hours) A. 2 Way to facilitate Closure-of Foramen-ovale 1. Tangential foot slap - So baby will cry to expand lungs - Never stimulate baby to cry when not yet properly suctioned - Check characteristics of cry (strong vigorous and lusty cry) - Cri – du – chat (meow cry) 2. Proper Positioning - Right side lying STRUCTURE APPROPRIATE TIME STRUCTURE FAILURE TO CLOSE OF OBLITERATION REMAINING Foramen Ovale 24 hours complete by 1 Fossa Ovalis Atrial Septal Defect year Ductus Arteriosus 24 hours complete by 1 Ligamentum Arteriosum Patent Ductus Arteriosus month Ductus Venosus 2 months Ligamentum Venosum Umbilical Arteries 2 – 3 months Lateral Umbilical Ligament Inferior Iliac Artery Umbilical Vein 2 – 3 months Lateral Umbilical Ligament Inferior Iliac Artery Ligamentum Teres (round ligament of liver) B. Best position immediately after birth: NSD – trendelendberg CS – supine or crib level position Signs of increase ICP 1. Abnormally large head 2. Bulging and tense fontanel 3. Projectile vomiting (surest sign of cerebral irritation) 4. Increase blood pressure but widening pulse pressure 5. Decrease respiratory rate 6. Decrease pulse rate 7. High pitch shrill cry (late sign) 8. Diplopia (sign of ICP from 6 months – 1 year) 3. Temperature Regulation Alerts: - The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC - Maintenance of temperature is important for preterm and SGA because it may lead to hypothermia or cold stress A. Factors Leading to the development of Hypothermia 1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature of environment due to immaturity of thermo regulating system of body 2. Inadequate subcutaneous tissue 3. Newborns are not yet capable of shivering (increase basal metabolism) 4. Babies are born wet B. Process of Heat Loss 1. Evaporation – body to air 2. Conduction – body to cold solid object 3. Convection – body to cooler surrounding air 4. Radiation – body to cold object not in contact with body C. Effects of Hypothermia (Cold Stress) 1. Hypoglycemia – due to utilization of glucose (40 – 45 gm/dl is the normal blood sugar of a newborn) 2. Metabolic Acidosis – due to catabolism of brown fats (best insulator of a newborn) 3. High risk for KERNICTERUS (bilirubin in brain) 4. Additional fatigue to already stressful heart D. Prevention of Cold Stress 1. Dry and wrapped newborns 2. Mechanical measures - Radiant warmer - Isolette (square acrylic sided incubator, must be pre heated first) 3. Prevent unnecessary exposure – cover areas not being examined 4. Use tin foil in absence of electricity 5. Embrace baby (called kangaroo care) 4. Establish Adequate Nutritional Intake Alerts: Breastfeed immediately for NSD and after 4 hours for CS (Colostrum is present on the 3 rd trimester) A. Physiology of Breast milk Production - Decrease in level of estrogen and progestin, stimulates the anterior pituitary gland, that stimulates the prolactin of the acinar cells (alveoli) to produce the foremilk stored in lactiferous tubules B. Advantage of Breastfeeding - Very economical - Always available - Promotes bonding - Helps in rapid involution - Decrease incidence of breast cancer - Breast fed babies has higher IQ - It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic bacteria in GIT - Contains macrophages (store in plastic container, good for 6 months when stored in freezer) - Disadvantages of breast milk and cow’s milk - Both has no iron - Possibility of transfer of HIV, Hepatitis B - Father cannot feed or bond as well C. Stages of Breastmilk 1. Colostrum – available 2 – 4 days after delivery Contents: - Low fats - Low carbohydrates - High protein - High immunoglobulin - High minerals - High fat-soluble vitamins 2. Transitional – covering 4 – 14 days Contents: - High lactose - High minerals - High water soluble vitamins 3. Mature milk – 14 days and above Contents: - High fats (linoleic acid responsible for integrity of skin and development of skin) - High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor of stool) - Low protein (lactalbumin) D. Cow’s milk Contents: - High fats - Low carbohydrates (add sugar) - High protein (casein) has a curd that is hard to digest - High minerals, has traumatic effect on kidneys of baby - High phosphorus that may cause inverse proportion with calcium E. Health Teachings 1. Proper Hygiene - Importance of hand washing - Removal of caked colostrum 2. Position - Upright sitting avoid tension to properly empty breast milk 3. Stimulate and evaluate feeding reflexes a. Rooting - touch side of lips or cheek and baby will turn to the stimulus - purpose: to look for food - disappear at 6 weeks because baby can already focus b. Sucking - by touching the middle of lips then baby will suck - purpose: take in food - disappear at 6 months - easily disappear when not stimulated c. Swallowing - food touches posterior portion of tongue automatically swallowed - never disappear cough, gag, sneeze d. Extrusion/Protrusion reflex - food touches anterior portion of tongue and tongue automatically extruded/protruded - purpose: prevent from poisoning - disappear by 4 months because baby can already spit out 4. The criteria of effective sucking a. baby’s mouth is hike well up to areola b. mother experiences after pain c. other nipple is flowing with milk 5. To prevent from crack nipples and initiate proper production of oxytocin - begin 2 – 3 minutes per breast - increase 1 minute per day each breast until you reach 10 minutes each breast or 20 minutes per feeding 6. For proper emptying and continuous milk production per feeding - feed baby on the last breast that you fed him PROBLEMS EXPERIENCED IN BREASTFEEDING a. Engorgement - soft and non tender (1 day) - feeling of tension and fullness of breast - while feeding warm compress - bottle feeding cold compress and wear supportive bra b. Sore nipple - cracked, wet and painful nipple - exposure to air is the management or 20 watt bulb - avoid wearing plastic liner bra, instead wear cotton bra c. Mastitis - inflammation of breast - causative factor: staphylococcus aureus - improper breast emptying - unhealthy sexual practices - breast feed on unaffected breast - express your breast on affected side - take antibiotic - increase 500 calories when breastfeeding - involution of breast is 4 weeks CONTRAINDICATIONS IN BREASTFEEDING Maternal Conditions - HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake Newborn Conditions - erythroblastosis fetalis - hydrops fetalis - phenylketonuria (PKU) - galactosemia - tay-sachs disease 5. Establishment of waste-elimination A. Different stools 1. Meconium - Physiologic stool - Blackish green - Sticky - Tar like - Odorless (because of sterile intestines) - No bacteria - Passed with in 24 – 36 hours - Failure to pass meconium suspect GIT obstruction a. hirschsprung b. imperforate anus c. meconium ileu (cystic fibrosis) 2. Transitional - Become green, loose and slimy that may appear to be a slight diarrhea to the untrained eye 3. Breastfed stool - Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring almost nearly every feeding 4. Bottle-fed stool - Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a day 5. With supplementary foods added - Brown and odorous B. Indication of Stool Changes - Light stool: jaundice baby - Bright green: phototherapy - Mucous mixed with stool: allergy - Clay colored: obstruction to bile duct - Chalk clay/whitish clay: barium enema - Black stool: GIT hemorrhage - Blood flecked: anal fissure - Curant jelly: intususeption - Ribbon like: hirschsprung - Steatorrhea: fatty, bulky, foul smelling – suspect malabsorption a case of cystic fibrosis or celiac disease ASSESSMENT FOR WELL-BEING A. APGAR SCORING Special Considerations - Taken on first 1 minute, shows the general condition of baby - 15 minutes is optional - Taken again after 5 minutes, to determine baby’s capability to adapt/ adjust extrauterinely Components Appearance - Color: slightly cyanotic, after first cry baby becomes pinkish Pulse rate - Apical pulse (left lower nipple) Grimace - Reflex irritability (foot slap, catheter insertion) Activity - Degree of flexion (muscle tone) Respiration APGAR SCORING CHART Score Criteria 0 1 2 Heart rate Absent Less than 100 More than 100 Respiratory effort Absent Slow irregular weak cry Good strong cry Muscle tone Flaccid extremities Some flexion Well flexed Reflex irritability Catheter No response Grimace Cough or sneeze Tangential Footslap No response Grimace Cry Color Blue/Pale Acrocyanosis Pink (body and extremities blue) Interpretation of APGAR Result 0-3: severely depressed, need CPR, admission to NICU 4-6: moderately depressed, additional suction and oxygen administration 7-10: good/healthy CARDIO PULMONARY-RESUSCITATION Airway (Clear Airway) 1. Shake, no response call for help 2. Place flat on bed 3. Head tilt – chin lift maneuver - Contraindicated to spinal cord injury - Over extension may occlude airway Breathing (Ventilating the lungs) 4. Check for breathlessness 5. Administer 2 rescue breaths Circulation (by cardiac compression) 6. Check for pulselessness 7. Do CPR (when breathless and pulse less) B. RESPIRATION EVALUATION SILVERMAN ANDERSON INDEX CHART Score Criteria 0 1 2 Chest movement Synchronized Lag on respiration See saw Intercostal retraction No retractions Just visible Marked Xiphoid retraction None Just visible Marked Nares dilation None Minimal Marked Expiratory grunt None Stethoscope Naked ear Interpretation of Result 0 – 3: Normal no respiratory distress syndrome 4 – 6: Moderate RDS 7 – 10: Severe RDS C. ASSESSMENT OF GESTATIONAL AGE BALLARD AND DOBOWITZ CLINICAL CRITERIA Gestational Age (Weeks) Findings Less THAN 36 37-38 39 and up Sole creases Anterior transverse Occasional creases in Sole covered with crease only 2/3 creases Breast nodule (dm.) 2 mm 4mm or 3 – 5 mm 7 mm – 7.5 mm Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky Ear Lobe Pliable Some Thick Testes Scrotum Testes and scrotum in Intermediate Testes pendulous, lower canal, scrotum is scrotum full with small with few rugae extensive rugae PRE TERM BABIES - 28 – 32 weeks - Frog leg or lax position - Hypotonic muscle tone - Scarf sign (elbow passes the midline) - Square window wrist (90o angle) - Heel to ear sign - Abundant lanugo - Prominent labia minora and clitoris POST TERM BABIES - More than 42 weeks - Old mans face (classic sign) - Desquamation (peeling of neonate skin characterized by extreme dryness than begin from sole and palm within 24 hours D. Neonate in the Nursery *Special and Immediate Interventions 1. Upon receiving - Proper identification (foot print with mothers thumb print) - Take antropometric measurement 2. Then take anthropometric measurements a. Length = 19.5 – 21 inches/47.5 – 53.75 cm average of 50 cm b. Head Circumference = 33 – 35 cm average of 34 cm/13 – 14 inches c. Chest Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches d. Abdominal Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches 3. Bathing Baby - Normal oil bath - Cleanse and spread vernix - Babies of HIV positive mothers are given full bath to lessen transmission of infection - Insulator - Bacteriostatic - Full bath is safely given when cord falls 4. Dressing the umbilical cord - Follow strict asepsis to prevent infection/tetanus - Use Povidone iodine - Check for 3 vessels (2 arteries and 1 vein) - AVA (2 vessel cord suspect kidney malformation) - Leave about 1 inch of cord - 8 inches if anticipating IV or BT - Check for the cord q 15 minutes for the first 6 hours - For bleeding: - 30 cc is bleeding to newborn - Hemophilia is excessive bleeding - Ompalagia is bleeding of the cord - Cord turns black on the third day - Falls by 7th – 10th day - Failure to fall is umbilical granulation (silver nitrate) - Use saline to clean 5. Credes Prophylaxis - Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment) 6. Administration of Vitamin K - Action: prevent hemorrhage - Related to physiologic hypoprothrombinemia - Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM) 7. Weight-taking Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs Arbitrary Lower Limit: 2500 grams Low Birth Weight: below 2500 grams Small for Gestational Age: less 10 percentile rank Large for Gestational Age: more than 90 percentile rank Appropriate for Gestational Age: within the 2 standard deviation of the mean Physiological Weight Loss: 5 – 10 percent occurs a few days after birth E. PHYSICAL EXAMINATION AND DEVIATIONS FROM THE NORMAL A. Important Considerations a. If the client is new born, cover areas that is not being examined b. If the client is infant, the first vital sign to take is RR (due to fear of stranger) - Begin at east intrusive to the most intrusive c. If the client is toddler and preschool, let them handle an instrument play syringe, stethoscope, d. If the client is school age and adolescent explain procedure COMPONENTS: 1. Vital signs - Temperature is taken rectally to rule out imperforate anus and thermometer is inserted 1 inch - Don’t force insertion because it may lead to pruritus - Types of imperforate anus a. Atretic – no anal opening, causing failure to pass meconium b. Agenetic - no anal opening, causing failure to pass meconium - abdominal distention - foul smelling stool - vomitus of fecal materials - respiratory problems - Management: surgery with temporary colostomy c. Membranous CARDIAC RATE 120-160/min - Irregular - Radial pulse is absent, if present suspect PDA CONGENITAL HEART DISEASES *Common in girls: PDA, ASD *Common in boys: TOGA (transposition of great arteries), Truncus Arteriosus *Causes: TOF 1. Familial 2. Exposure to rubella (1st month for mother) 3. Failure of heart structure to progress TWO MAJOR TYPES A. ACYANOTIC HEART DEFECTS Left to right shunting WITH INCREASED PULMONARY BLOOD FLOW 1. Ventricular Septal Defect - Opening between 2 ventricles Signs and Symptoms 1. Systolic murmur at lower border of sternum and no other significant signs 2. Cardiac catheter reveals oxygen saturation at right side of heart 3. ECG reveals hypertrophy of right side of heart Management 1. Long term antibiotic therapy to prevent development of sub acute bacterial endocarditis 2. Open heart surgery 2. Atrial Septal Defect - Failure of foramen ovale to close Signs and Symptoms 1. Systolic murmur at upper border of sternum and no other significant signs 2. Cardiac catheter reveals increase oxygen saturation at right side of heart 3. ECG reveals hypertrophy of right side of heart 3. Endocardial Cushion Defects - AV canal affecting both tricuspid and mitral valve Signs and Symptoms 1. Only confirmed by cardiac catheter Management - Open heart surgery 4. Patent Ductus Arterious - Failure of ductus arteriosus to close Signs and Symptoms 1. Continuous machine like murmur 2. Prominent radial pulse 3. Hypertrophy of left ventricle upon ECG Management 1. INDOMETHACIN (prostaglandin inhibitor that facilitate closure of PDA) 2. Ligation of PDA by 3 – 4 years old WITH DECREASED PULMONARY BLOOD FLOW 1. Pulmonary Stenosis - Narrowing of valve of pulmonary artery Signs and Symptoms 1. Typical systolic ejection murmur 2. ECG reveals hypertrophy of right ventricle 3. S2 sound is widely split 2. Aortic Stenosis - Narrowing of valve of aorta Signs and Symptoms 1. Left ventricular hypertrophy 2. Typical murmur Management 1. Balloon stenotomy 2. Surgery (last resort) 3. Duplication of aortic arch - Doubling of arch of aorta causing compression to trachea and esophagus Signs and Symptoms 1. Dysphagia 2. Dyspnea Management 1. Close heart surgery 4. Coarctation of the Aorta - Narrowing of arch of aorta Signs and Symptoms 1. Blood pressure in upper extremities is increased 2. Blood pressure in lower extremities is decreased 3. Outstanding sign is absent femoral pulse Management 1. Take blood pressure in 4 extremities 2. Close heart surgery B. CYANOTIC HEART DEFECTS Right to left shunting WITH INCREASE PULMONARY BLOOD FLOW 1. Transposition of Great Arteries - Situation where aorta is arising from the right ventricle and pulmonary artery of the left ventricle Signs and Symptoms 1. Cyanosis after 1st cry (outstanding sign) 2. Polycythemia (compensatory mechanism to decrease oxygen supply 3. Prone to thrombus leading to embolism resulting to stroke (complications) Management 1. Palliative repair – kashkind procedure 2. Complete repair – mustard procedure 2. Total Anomalous Pulmonary Venous Return - Pulmonary vein enters the right atrium or superior vena cava Signs and Symptoms 1. Mixed blood supplying the body (oxygenated and unoxygenated) 2. Open foramen ovale 3. Aspleenia (absent spleen) 4. Mild to moderate cyanosis Management 1. Restructuring of the heart 3. Truncus Arteriosus - Pulmonary artery and aorta is arising from one common trunk or single vessel with VSD Management 1. Positive cyanosis and polycythemia 2. Restructuring of the heart 4. Hypoplastic Left Heart Syndrome - Non functioning left ventricle Signs and Symptoms 1. Cyanosis 2. Polycythemia Management 1. Heart transplant WITH DECREASE PULMONARY BLOOD FLOW 1. Tricuspid atresia - Failure of tricuspid valve to open Signs and Symptoms 1. Open foramen ovale 2. Cyanosis Management 1. Fontan procedure 2. Tetralogy Fallot - 4 Anomalies Present Pulmonary stenosis VSD Overriding aorta Right ventricular hypertrophy Signs and Symptoms 1. High degree of cyanosis 2. Polycythemia - Increase red blood - Thrombus, embolus, stroke - Mental retardation - Clubbing of fingernails (chronic tissue hypoxia) late sign - X-ray reveals boot shape heart 3. Severe dyspnea - Relieved by squatting position 4. Growth retardation 5. Tet Spells - Blue spells, short episode of hypoxia Management 1. Morphine – for hypoxic episode 2. Propranolol (Inderal) – decrease heart spasm 3. Palliative Repair – BLALOCK TAUSSIG PROCEDURE 4. Complete Repair – BROCK PROCEDURE ACQUIRED HEART DISEASE Rheumatic heart Disease - Inflammatory disease following an infection caused by Group-A beta hemolytic streptococcus (thrives in aerobic environment) Affected Body Parts - Musculoskeletal – cardiac muscles and valves - Integumentary - CNS - Aschoff bodies - Rounded nodules containing of multi nucleated cells and fibroblasts that stays in mineral valve Signs and Symptoms MAJOR MINOR Polyarthritis (multi joint pain) Arthralgia (joint pain) Chorea (sydenhanns chorea) St. Vitus Low grade fever dance, purposeless/involuntary hand and Increase diagnostic tests shoulder movement accompanied by a. Antibody grimace b. C-reactive protein Carditis c. Erythrocyte Sedimentation Rate Errythema marginatum (macular rash) d. Anti-streptolysin O titer (ASO) - Subcutaneous nodules Management - CBR (avoid contact sports) - Culture and sensitivity (throat swab) - Antibiotic management (to prevent recurrence) - Aspirin (anti inflammatory) - Side Effects: Reye’s Syndrome - Non recurring encephalopathy accompanied by fatty infiltration of organs such as liver and brain RESPIRATION - Abnormal/diaphragmatic - Short period of apnea without cyanosis - Normal apnea of newborn is less than 15 seconds Respiration Check Newborn 40-90 5 years 20-25 1 year 20-40 10 years 17-22 2-3 years 20-30 15 and above 12-20 Breath Sounds Heard on Auscultation Sound Characteristics VESICULAR Soft, low pitched, heard over periphery of lungs, inspiration longer than expiration, normal. BRONCHOVESICULAR Soft, medium-pitched, heard over major bronchi, inspiration equals expiration, normal. BRONCHIAL Loud, high-pitched, heard over trachea, expiration longer than inspiration, normal. RHONCHI Snoring sound made by air moving through mucus in bronchi, normal. RALES Crackles (like cellophane) made by air moving through fluid in alveoli. Abnormal; denotes pneumonia or pulmonary edema which is fluid in alveoli. WHEEZING Whistling on expiration made by air being pushed through narrowed bronchi. Abnormal; seen on children with asthma or foreign-body obstruction. STRIDOR Crowing or rooster like sound made by air being pulled through a constricted larynx, Abnormal, seen in infants with respiratory obstruction. RESONANCE Loud, low tone, percussion sound over normal lung tissue. HYPERRESONANCE Louder, lower sound than resonance, a percussion sound over hyperinflated lung issue. RESPIRATORY DISTRESS SYNDROME - Hyaline membrane disease - Cause: lack of surfactant - Common in preterm infants - Hypoxic - Formation of hyaline - Causing atelectasis Signs and Symptoms - Definite within 4 hours of life 1. Increase RR with retractions (early sign) 2. Expiratory grunting (major sign) 3. Flaring alae nassi 4. Xiphoid retractions 5. Intercoastal retractions 6. Respiratory acidosis Management 1. Keep head elevated 2. Proper suctioning - Oxygen administration - Place on continuous positive airway pressure - Positive end expiratory pressure (maintain alveoli partially open and prevent collapse) 3. Monitor skin color, vital signs, ABG 4. Surfactant replacement and rescue LARYNGOTRACHEOBRONCHITIS - Infection of larynx, trachea and bronchi Assessment - Barking cough/croupy cough - Respiratory acidosis Laboratory Studies a. ABG b. Throat culture c. CBC Diagnostic Studies a. Chest and neck x-ray (to rule out epiglotitis) Management a. Bronchodilators b. Oxygen with increase humidity c. Prepare tracheostomy set when necessary Broncholitis - Inflammation of bronchioles characterized by production of thick tenacious mucous Signs and Symptoms - Cold like/flu like symptoms - Causative agent: respiratory syncitial virus - Drug: Ribavirin (anti viral drug) - End stage epiglotitis (emergency condition or URTI), sudden onset Management - Tripod position (leaning forward with tongue protrusion) - Never use tongue depressor - Prepare tracheostomy set - Encircle age - Mist tent “croup tent”, croupette - Nursing management a. Check edges if properly tucked b. Washable plastic material c. Avoid toys that cause friction and hairy and furry materials BLOOD PRESSURE - 80/46 mmHg after 10 days 100/50 - Normal blood pressure taking begins by 3 years old Alerts - BP cuff must cover 50 – 75% (2/3) of upper arm - To large cuff results to false low BP - To small cuff results to false high BP SKIN - Acrocyanosis (body pink extremities blue) - Generalized mottling due to the immaturity of the circulatory system BIRTHMARKS 1. Mongolian Spots – slate-gray-or-bluish discoloration/patches commonly seen across he sacrum or buttocks - Due to increase melanocytes - Common in asian newborn - Disappear by 1 year, preschool, 5 years old 2. Milia – plugged unopened sebaceous gland usually seen as white pinpoint patches on nose, chin and cheek, disappears by 2 – 4 weeks 3. Lanugo – fine downy hair 4. Desquamation – peeling of the newborn skin within 24 hours, common among post term 5. Stork bites (telengiectasis nevi) – pink patches at the nape of the neck - Never disappear but is covered by hair 6. Erythema Toxicum (flea bite rash) – first self limiting rash to appear sporadically and unpredictably as to time and place. 7. Harlequin sign – dependent part is pink, independent part is blue (RBC settles down) 8. Cutis marmorata – transitory motling of neonates skin when exposed to cold 9. Hemangiomas – vascular tumors of the skin 3 TYPES a. Nevus Flammeus – macular purple or dark red lesions usually seen on the face or thigh - Portwine stain: never disappear but can be removed surgically b. Strawberry hemangiomas (nevus vasculosus)– dilated capillaries in the entire dermal or subdermal area continuing to enlarge but disappear after 10 years old. c. Cavernous hemangiomas – Consist of communicating network of venules in the subcutaneous tissue that never disappear with age. - Dangerous type may lead to internal hemorrhage 10. Vernix Caseosa – white cheese like substance for lubrication; Color of vernix is same as amniotic fluid SKIN COLOR AND THEIR SIGNIFICANCE Blue – cyanosis/ hypoxia White – edema Gray – infection Yellowish – jaundice/ carotinemia (increase carotin) Pale – anemia SKIN DISORDERS BURN TRAUMA - Is injury to body tissue cause by excessive heat Assessment Depth 1st (partial thickness) Ex. Sunburn Involves only the superficial epidermis characterized by erythema, dryness and pain Heals 1 -10 days 2nd (partial thickness) Ex. Scalds Involves the entire epidermis, and portion of dermis characterized by erythema, blistered and moist from exudates which is extremely painful. 3rd (full thickness) Involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia, muscle and bone. It appears leathery, white or black and not sensitive to pain since nerve ending had been destroyed. Management 1. First Aid a. Put out flames by rolling the child on a blanket b. Immerse the burned part on cold water c. Remove burned clothing d. Cover burn with sterile dressing 2. Maintenance of a patent airway a. Suction as needed b. Oxygen administration c. ET tube d. Tracheostomy 3. Prevention of Shock and Fluid and Electrolyte Balance a. Colloids to expand blood volume b. Isotonic saline to replace electrolytes c. Dextrose and water provide calories 4. A booster dose of tetanus toxoid 5. Relief of pain such as IV analgesic (morphine sulfate) 6. Prevention of wound infection a. Cleaning and debriding of wound b. Open/close method of wound care c. Whirlpool therapy 7. Skin grafting a. Big skin xenograft b. Taken from cadaver 8. Diet a. High protein b. high calorie ATOPIC DERMATITIS - Infantile eczema - Skin disease characterized by maculo vesicular errythematous lesion with weeping and crusting - Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat - Characterized by extreme pruritus - Sign: linear excoriation, lichenified – scaling Management - Treat main cause - Prosorbbee or Isomil (milk) - Hydrate skin with burrow’s solution - Prevent infection - Cut short the nails IMPETIGO - Cause: group A beta hemolytic streptococcus - Characterized by populo vesicular surrounded by localized errythema becoming purulent and ooze forming a honey colored crust - Pediculosis capitis (kuto) - Give oral penicillin - AGN complication ACNE - Self limiting inflammatory disease affects sebaceous glands common in adolescence - Signs: Comedones (sebum causing white heads) - Sebum is composed of lipids Management - Proper hygiene - Wash face with soap and water - Use sulfur soap or mild soap - Retin A HEMATOLOGIC DISORDERS PALLOR-ANEMIA Possible cause of Anemia 1. Early cutting of cord 2. Bleeding Disorder/blood dyscracia HEMOPHILIA - Deficient clotting factor - X link recessive inheritance - Sex link - Excessive bleeding upon cutting of cord or circumcision - Carrier mother passed to son, when son becomes a father he will pass it to his daughter Hemophilia A (classic) – deficiency of the coagulation component (Factor VIII) Hemophilia B (Christmas disease) – deficiency in clotting factor IX Hemophilia C – deficiency in clotting factor XI Assessment - Newly delivered baby receive maternal clotting factor - Sudden bruising of bumped area - Continuous bleeding to hemarthrosis - Bleeding or damage of synovial membrane Diagnostic Test - High risk for injury (prevent injury) - Partial thromboplastin time Management - Avoid contact sports - Significance: determine case before doing any invasive procedure - No aspirin - Immobilize and elevate upon injury - Apply gentle pressure - Cold compress - Blood transfusion: cryoprecipitate, fresh frozen plasma LEUKEMIA - Group of malignant disease characterized by rapid proliferation of immature WBC - WBC (soldiers of body) - Ratio: 500 RBC:1WBC Classification (depends on affected part) Lympho – lymphatic system Myelo – bone marrow Acute/Blastic – immature cells Chronic/cystic – mature cells Acute lymphocytic – common among children Signs and Symptoms 1. From the invasion of bone marrow - Anemia (pallor, fatigue, constipation) - Bleeding (bruising, petechiae, epistaxis, bleeding in urine, emesis) - Infection - Fever - Poor wound healing - Bone weakens and causes fracture 2. From the invasion of organs - Hepatosplenomegaly - CNS affectation (headache and signs of increase ICP) Diagnostic Tests and Studies 1. PBS (peripheral blood smear) – determine immature WBC 2. CBC – anemia, neutropenia, thrombocytopenia 3. Lumbar Puncture – place in fetal position without flexion of neck, C position or shrimp position 4. Bone Marrow Aspiration - Site for aspiration is the iliac crest - Put pressure after aspiration - Place on affected side 5. Bone Scan – determine bone involvement 6. CT scan– determine organ involvement Surgery TRIAD Irradiation Chemotherapy Therapeutic Management 1. Medications 4 Levels of Chemotherapy For Induction – achieve remission (main goal) a. IV Vincristine b. Laspariginase c. Oral prednisone For Sanctuary – treat leukemic cells that has invaded testes and CNS a. Methothrexate (intrathecally via CNS/spine) b. Cytocin c. Arabinoside d. Extra irradiation For Maintenance – continue remission a. Oral Methothrexate b. Oral 6 mercaptopurine c. Cytarrabine For Reinduction – treat leukemic cells after relapse occurs a. IV Vincristine b. Laspariginase c. Oral prednisone Antigout Agents – treat/prevent hyperuricemic nephropathy a. Allopurinol (Zyloprim) b. Increase fluid intake Nursing Management - Assess for common side effects - Nausea and vomiting - Administration of anti emetics 30 minutes before chemo and continue until 1 day after - Check for stomatitis, ulcerations and abscess of oral mucosa - Oral care (alcohol free mouthwash) no toothbrush - Diet (soft and bland) according to child’s preference - Alopecia (temporary side effects) - Hirsutism - To parents (always repeat instruction) HEMOLYTIC DISORDER a. Rh Incompatibility - Mother negative, fetus positive - 4th baby affected - Mother negative, no antigen (no protein factor) - Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity with pathologic jaundice within 24 hours - Test: Comb’s Test - Vaccine: Rhogam - Given to RH negative mother within first 72 hours to destroy fetal RBC therefore preventing antibody formation b. ABO Incompatibility - Mother is type O, fetus is type A, B, AB - Most common is O, and A - Severe O and B - First pregnancy can be affected Assessment - Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice within 24 hours Management 1. Initiation of feeding, temporary suspension of breast feeding to prevent kernikterus 2. Pregnandiole – delays action of glucoronyl transferace (liver enzyme that converts indirect bilirubin to direct bilirubin) 3. Use of Phototherapy 4. Exchange Transfusion of Rh or ABO affectations that tend to cause continuous decrease in hemoglobin during the first 6 months because bone marrow fails to produce erythrocytes in response to continuing hemolysis. Yellow – Jaundice Hyperbilirubinemia - Normal: indirect bilirubin 0 – 3 mg/dl - More than 12 mg/dl of indirect bilirubin in fullterm Kernicterus - Bilirubin encephalopathy more than 20 mg/dl indirect bilirubin in fullterm - Less than 12 mg/dl in preterm because of immature liver Physiological Jaundice - Icterus neonatorum - 48 – 72 hours - Expose to sunlight Pathological Jaundice - Icterus gravis neonatorum - Clinical jaundice within 24 hours Breastfeeding Jaundice - Pregnandiole - 6 to 7 days Assessment - Blanching the neonates forehead , nose or sternum - Yellow skin and sclera - Light stool - Dark urine Management Phototherapy - Photo oxidation - Height of 18 – 20 inches away from baby Nursing Responsibilities 1. Cover the eyes – prevent retinal damage 2. Cover genitals – prevent priapism (painful continuous erection) 3. Change position – for even exposure to light 4. Increase fluid intake – to prevent dehydration 5. Monitor I & O – weigh baby 1 gram:1 cc 6. Monitor Vital Signs - Avoid use of lotion or oil because it may result to bronze baby syndrome HEAD Structures Sutures: 3 Fontanels: 12 – 18 months close Anterior fontanel - Craniostenosis/ craniosinostosis (premature closure of anterior fontanel) Posterior fontanel - 1 x 1 cm - Closes by 2 – 3 months Microcephaly - Small/slow growing brain - Fetal alcohol and HIV positive Anencephaly - Absence of cerebral hemisphere Noticeable Structure of the head 1. Craniotabes - Localized softening of cranial bones to 1st born child due to early lightening - Ricketts in older children 2. Caput Succedaneum - Edema of scalp due to prolonged pressure at birth - Characteristics - Present at birth - Crosses the suture line - Disappear after 2 – 3 days 3. Cephalhematoma - Collection of blood due to rupture of periostial capillaries - Characteristics - Present after 24 hours - Never cross the suture line - Disappear after 4 – 6 weeks 4. Seborrheic Dermatitis - Cradle cap - Scaling, greasy appearing salmon colored patches usually seen on scalp, behind ears and umbilicus - Primary cause: improper hygiene - Management: proper hygiene, apply oil the night before shampooing (use baby oil or coconut oil) 5. Hydrocephalus - Collection of CSF 2 types a. Communicating – extra ventricular hydrocephalus b. Non communicating – intra ventricular hydrocephalus also called obstructive Signs and Symptoms - Sign of increase ICP - Sign of frontal bossing (prominent forehead) - Prominent scalp vein - Sunset eyes Therapeutic Management - Place client in low semi fowlers position (30o) - Osmotic diuretic - Diamox (Acetazolamide) to decrease CSF production - Seizure precaution - Surgery (AV shunt, VP shunt) - Shave just before surgery - Place in side lying position on non operated side - Monitor for good drainage - Sunken fontanel is a good sign - Mental retardation depend on extent of hydrocephalus SENSES a. Sense of Sight (Eyes) Sclera – light blue becomes dirty white Pupils – round and adult size a. Coloboma – part of iris is missing b. Congenital cataract – whiteness and opacity (caused by german measles) Cornea – round and adult size, larger in congenital glaucoma Test of blindness AGE COMMON TEST 1. Newborn - General appearance - See 10 – 12 inches - Doll’s eye test done on 10th day - Glabellars test blink reflex 2. Infant and children - General appearance - Ability to follow object past midline 3. 3yr – school age - Pre school - E chart test for stereosis or depth of perception - Allen cards for visual acuity - Ishiharas plates for color blindness - Cover testing for strabismus, eye deviation 4. School Age – Adult - Snellen’s test RETINOBLASTOMA - Malignant tumor of retina - Red painful eye often accompanied by glaucoma (pathognomonic sign: cat’s eye reflex) - Management: enucleation b. Senses of Smell (Nose) - Flaring or alae nasi (RDS) - Pale with creases nasal membrane, chronic rhinitis - Inflamed: infection - Cocaine abuse: - No hair - Ulceration with abscess at the nasal mucosa - Perforation of nasal septum - Epistaxis: - Nose bleed - Sit upright with head tilted forward - Cold compress - Apply pressure - Give epinephrine c. Sense of Hearing (Ears) - First to develop and last sense to disappear - Properly aligned to outer canthus of eye 1. Kidney Malformation - Low set ears - Renal agenesis - Unilateral/bilateral - Oligohydramnios (sign of renal agenesis in utero) - Failure to fade 24 hours - Kidney transplant 2. Chromosomal Aberrations - More than 35 years A. Nondisjunction 1. Trisomy 21 - Down syndrome - Extra chromosome 21 - 47 XX + 21 or 47 XY + 21 - Cause: advance paternal age - Mongolian slant in eyes - Low set ears - Broad flat nose - Protruding tongue - Puppy’s neck - Hypotonic (respiratory problem unable to cough out) - Simian crease (single transverse line of palm) - Educable 2. Trisomy 18 3. Trisomy 13 4. Turners 5. Klinefilters Syndrome B. Deletion Abnormalities 1. Cri-du-chat Syndrome 2. Fragile X Syndrome C. Translocation Abnormalities 1. Balance Translocation Carrier 2. Unbalanced Translocation Syndrome D. Others 1. Mosaicism – a situation wherein the nondisjunction of chromosomes occurs during the mitotic cell division after fertilization resulting to different cells contains different numbers of chromosomes. 2. Isochromosomes – a situation wherein the chromosomes instead of dividing vertically it divides horizontally resulting to chromosomal mismatch. OTITIS MEDIA - Inflammation of middle ear, common in children due to wider and shorter eustachian tube - Common with cleft lip and palate - Bottle propping, may also result to dental caries - Otoscopic: bulging tympanic membrane and absence of light reflex - Observe for passage of milky, purulent and foul smelling odor discharge - Observe for URTI Management - Side lying on affected side to facilitate drainage - Supportive care (TSB, antipyretic) - Massive dosage of antibiotic (may lead to bacterial meningitis) - Apply ear ointment a. below 3 years down and back b. above 3 years up and back - Mucolytics to shrink mucous - Myringotomy: surgical procedure done by making a slight incision of the tympanic membrane - Place client on the operated side - To prevent permanent hearing loss MOUTH AND TONGUE a. Bels Palsy - Facial nerve paralysis - VII cranial nerve injury - Related to forcep delivery Signs and Symptoms - Continuous drooling of saliva - Inability to open 1 eye and close other eye Management - Artificial tears - Refer to PT (self limiting) b. TEF/TEA - Tracheo Esophageal Fistula. Tracheo Esophageal Atresia - No connection between esophagus and stomach - 4 C’s: coughing, choking, cyanosis, continuous drooling - Emergency surgery c. Epstein Pearls - White glistening cyst usually seen on palate or gums related to hypercalcemia d. Natal Tooth - Tooth at moment of birth related to hypervitaminosis (rootless) e. Neonatal Tooth - Tooth within 28 days f. Oral Thrush - Oral moniliasis, white cheese/curd like patches that coats mouth and tongue - Treat with anti fungal (Nistatin/Mycostatin) g. Anodontia - No eruption of temporary teeth KAWASAKI DISEASE - Common in Japan - Mucocutaneous lymph node syndrome - Drug of choice: Aspirin, Salicylates Criteria for diagnosis of Kawasaki Disease 1. Fever lasting more than 5 days 2. Bilateral Conjunctivitis 3. Change of lips and oral cavity a. Dry, red, fissure lips b. Strawberry tongue c. Diffuse erythema of mucous membrane 4. Changes of peripheral extremities a. Erythema of the palms and sole b. Indurative edema of the hands and feet c. Membranous desquamation from fingertips 5. Polymorphous rash (primarily on trunk) 6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter CLEFT LIP - Failure of the median maxillary nasal processes to fuse by 5 – 8 weeks of pregnancy - Common in boys - Can be unilateral or bilateral CLEFT PALATE - Failure of the palate to fuse by 9 – 12 weeks of pregnancy - Common in girls Signs and Symptoms a. Evident at birth b. Ultrasound/3 dimensional UTZ c. Milk escape to the nostril d. Common URTI (otitis, cholic) Therapeutic Management - Surgery - Cleft lip: cheiloplasty done as early as 1 – 3 months to save sucking reflex - Cleft palate: uranoplasty done 4 – 6 months to save speech Nursing Responsibility (Pre Op) - Emotional support - Proper nutrition - Use Rubber tipped medicine dropper - Prevention of cholic a. Feed upright position b. Burp twice c. Prone position/on abdomen - Orient parents to feeding technique Cleft Lip - Use rubber tipped syringe Cleft Palate - Use paper cup, plastic cup, soup spoon - Use elbow restraints (pre op) - So baby can easily adjust post op (Post Op) - Maintenance of airway - Side lying (cheiloplasty) - Prone (uranoplasty) - Facilitate drainage - Monitor for developing RDS - Proper nutrition - NPO 4 hours post op - Check for colds or nasopharyngitis - May cause septicemia - Begin with clear liquid - Observe for signs of hemorrhage (frequent swallowing) - Usually happens 6 – 7 days post op - Protect site of operation - Maintain integrity of logan bar a. Half strength hydrogen peroxide and saline b. Prevent baby from crying c. Prevent cholic d. Check for wet diaper NECK - Check for symmetry a. Congenital Torticolis - Wry neck - Birth injury of sternocleidomastoid muscle due to excessive traction during cephalic delivery - Management: - Passive stretching exercises daily - Surgery (last) - Complication is scoliosis b. Congenital Cretinism (congenital hypothyroidism) – absence or non-functioning thyroid glands Signs and Symptoms 1. Change in sucking (early sign) 2. Change in crying 3. Sleep excessively due to decrease metabolism 4. Constipation 5. Moon face baby 6. Mental retardation (late sign) Diagnostic Exam - Radio active iodine uptake - Protein bound iodine - radio immuno assay test Reasons for delayed diagnosis - Thyroid glands are covered by sternocleidomastoid - Baby receive maternal thyroxine - Sleep 16 – 20 hours a day Management - Synthroid (synthetic thyroid) - Sodium Levothyroxine (given lifetime) CHEST - Check for symmetry - Breast produces witch milk a transparent fluid related to hormone changes ABDOMEN - Inspection, Auscultation, Palpation, Percussion A. Diaphragmatic hernia - Protrusion of stomach contents through a defect in the diaphragm due to failure of pleuroperitoneal canal to close Signs and Symptoms 1. Sunken abdomen 2. Signs of RDS 3. Related to shunting Management - CPAP (continuous positive airway pressure) - Diaphragmatic repair within 24 hours B. Ompalocele - Protrusion of stomach contents between junction of abdominal wall and umbilicus - Small: surgery - Large: - Suspension of surgery - Wrap with sterile wet dressing - Apply silver sulfadiazine ointment to prevent infection GASTROINTESTINAL SYSTEM 1. FUNCTIONS a. Assists in maintaining fluid and electrolyte and acid/base balance b. Processes and absorbs nutrients to maintain metabolism and support growth and development c. Excrete waste products from the digestive system 2. RECOMMENDED DAILY ALLOWANCE a. Calories: 120 calories per kilo body weight per day (360 – 380 calories) b. Fluids: 16 – 20 cc per kilo body weight c. Protein: 2.2 grams per kilo body weight 3. SUPPLEMENTARY FEEDING 4 – 6 months Principles a. Solid food is offered to the following sequence - Cereals: rich in iron (because at 6 months iron is completely catabolized) - Fruits - Vegetables - Meat b. Begin with small quantities c. Finger food is deferred by 6 months d. Soft table food/modified family menu by 1 year e. Dilute fruit juices (6 months) - Ratio: 1 oz. fruit to 4 oz. water - Never give half cooked egg, may cause gastroenteritis/salmoneliosis diarrhea - Avoid giving honey cause infant botulism - Offer new food 1 at a time with interval of 4 – 7 days to determine food allergies 4. MAJOR CONCEPTS OF FLUID AND ELECTROLYTE BALANCE Distribution of body fluid - Total body fluids comprises of 65 – 85% body weight among infants and children - Fluids are greater ECF compartment among infants and children (prone to dehydration) 5. ACID-BASE BALANCE Dependent on the following a. Chemical buffers b. Renal and respiratory system involvement c. Dilution of strong acids and bases on blood Imbalance of acid a. Respiratory acidosis - Carbonic acid excess - Hypoventilation - Asthma - Pneumonia - Emphysema - Laryngo tracheo bronchitis - RDS b. Respiratory alkalosis - Carbonic acid deficit - Hyperventilation - Fever - Encephalitis c. Metabolic acidosis - Carbonate deficit - Diarrhea - Severe malnutrition - Dehydration - Celiac crisis d. Metabolic alkalosis - Carbonate excess - Uncontrolled vomiting - Gastric lavage - NGT aspiration - Pyloric stenosis 6. CONDITIONS THAT PRODUCE FLUIDS AND ELECTROLYTES IMBALANCE A. Vomiting - Forceful expulsion of stomach contents Signs and Symptoms a. Nausea b. Dizziness c. Abdominal cramping d. Flushing of face e. Teary eyes Assessment - Amount - Frequency - Force (projectile:IC, pyloric stenosis) Management Banana Rice, cereal Apple sauce Toast B. Diarrhea - Exaggerated excretion of intestinal content 1. Acute diarrhea are associated with the following a. Gastroenteritis, caused by salmoneliosis (half cooked egg) b. Antibiotic use c. Dietary indescretions 2. CNSD (Chronic Non Specific Diarrhea) a. Food intolerance b. Carbohydrates and Protein malabsorption c. Excessive fluid intake Assessment - Frequency - Consistency - Appearance of green color stool Complications Dehydration 1. Mild – 5% weight loss 2. Moderate – 10% weight loss 3. Severe – 15% weight loss Signs of dehydration 1. Tachycardia 2. Tachypnea 3. Hypotension 4. Increase temperature 5. Sunken fontanel and eyeballs 6. Poor skin turgor/dry skin and mucous membrane 7. Absence of tears 8. Scanty urine (mark oliguria sign of severe dehydration) 9. Weight loss 10. Prolonged capillary refill time Management 1. Acute – NPO to rest bowel, IV infusion 2. Potassium Chloride – check if baby can void because it can lead to hyperkalemia leading to cardiac arrest 3. Sodium Bicarbonate – metabolic acidosis, administered slowly to prevent cardiac arrest 7. GASTRIC MOTILITY DISORDER HIRSCHPRUNGS DISEASE - Congenital gagnlionic mega colon - Absence of gagliion cells for peristalsis Assessment 1. Neonatal Period - Failure to pass meconium after 24 hours 2. Early Childhood a. Ribbon like stool b. Constipation c. Diarrhea d. Foul smelling stool Signs and Symptoms - Foul odor breath with stool - Vomitus of fecal materials Management - NGT feeding - Surgery a. Temporary colostomy (at 2 -3 months) b. Anastomosis and pull through procedure - Diet: high calorie and low residue (spaghetti and chicken) Diagnostic Procedures 1. Barium Enema – reveals the narrowed portion of the bowel 2. Rectal Biopsy 3. Abdominal x-ray – reveals dilated loops on intestine 4. Rectal manometry – reveals failure of intestinal sphincter to relax Therapeutic Management and Nursing Care GASTROESOHAGEAL REFLUX (GER) - Chalasia presence of stomach contents in esophagus Assessment Findings a. Chronic vomiting b. Failure to thrive syndrome (organic) c. Esophageal bleeding manifested by Effects and complication - Esophagitis - Aspiration - Carcinoma Diagnostic procedures 1. Barium Esophogram 2. Esophageal Manometry – reveals lower esophageal sphincter pressure 3. Intraesophageal pH content – reveals pH of distal esophagus Medications 1. Cholinergics a. Betanicole (Urecholine) - to increase esophageal tone and peristaltic activity b. Metochlopromide (Reglan) – to decrease esophageal pressure by relaxing pyloric and duodenal segments increasing peristalsis without stimulating secretion c. Histamine receptor antagonist (Ranitidine/Zantac) – to decrease gastric acidity and pepsin secretion d. Antacid (Maalox) – to neutralize gastric acid between feedings Management 1. Administration of thickened feeding with cereal to prevent vomiting 2. Feed slowly 3. Burp often every 1 oz. 4. Position: below 9 months place in prone with head of mattress slightly elevated on a 30 O angle 5. Surgery: fundoplication 8. OBSTRUCTIVE DISORDERS PYLORIC STENOSIS - Hypertrophy of pylorus muscle causing narrowing and obstruction Assessment 1. Projectile vomiting Nursing Alerts: - Vomiting is an initial symptom of upper GI obstruction - Vomitus of upper GI can be blood tinged not bile streaked - Vomitus of lower GI is bilous - Projectile vomiting is either a sign of ICP or GI obstruction - Abdominal distention is the major symptom of lower GIT obstruction 2. Failure to gain weight 3. Palpate olive shape mass 4. Peristaltic wave visible from left to right across epigastrium Diagnostic Procedures 1. ABG – metabolic alkalosis 2. Serum electrolyte: increase Na and K, decrease chloride 3. Ultrasound 4. X-ray of upper abdomen with barium swallow reveals string sign Therapeutic Management - Surgery: pyloromyotomy INTUSSUSCEPTION - Telescoping of one portion of the bowel to another - Complication of peritonitis Signs and Symptoms - Acute paroxysmal abdominal pain - Vomiting - Curant jelly stool - Sausage shape mass Diagnostic test - X-ray with barium enema reveal staircase sign Management - Hypostatic reduction with barium enema 9. INBORN ERRORS OF METABOLISM - Deficient liver enzyme PHENYLKETONURIA - Deficiency of liver PHT (Phenylalanine Hydroylase Transferase) - No tyrosine, melanin, tyroxine – basal metabolism Signs and Symptoms - Fair skin - Blonde hair - Blue eyes - Accumulation of phenyl pyrobic acid in the blood - Musty or mousy odor urine - Atopic dermatitis - Seizure - Mental retardation Diagnostic Tests a. Guthrie test Management - Low phenylalanine indefinitely - No food rich in protein (chicken, eggs, meat, legumes, peanut) - Lofenalac CELIAC DISEASE - Gluten Enteropathy - Intolerance to foods containing barley, rye, oats, wheat (normally converted to gluten) - With celiac disease gluten is converted to gliadin (toxic to the epithelial cells of villi leading to malabsorption of: - Fats (steatorrhea), Protein and Carbohydrates (malnutrition), Calcium (osteomalacia), Vitamin K (bleeding), Vitamin B12 (anemia) Assessment 1. Early signs a. Diarrhea; failure to regain weight ff diarrheal episodes b. Constipation c. Vomiting d. Abdominal Pain e. Steatorrhea 2. Late signs a. Behavioral changes: irritability and apathy b. Muscle wasting and loss of subconscious fats (protuberant abdomen) 3. Celiac Crisis a. Exaggerated form of vomiting (emergency condition) Diagnostic Procedures 1. Laboratory Studies: Stool Analysis 2. Serum antigliadin and antireticulin antibodies – presence indicates disorder 3. Sweat test – to rule out cystic fibrosis Therapeutic Management 1. Vitamin supplements 2. Mineral supplements 3. Steroids 11. POISONING - Common among toddlers Principles 1. Determine the substance taken, assess LOC 2. Unless the poison was corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove the poison from the body 3. Syrup of ipecac – oral emetic to cause vomiting after drug over dose or poisoning a. 15 ml to adolescent, school age and pre school b. 10 ml to infant 4. Universal antidote – charcoal, milk of magnesia, and burned toast 5. Never administer the charcoal before ipecac 6. Antidote for Acetaminophen poisoning. Acetylsysteine (Mucomyst) 7. For caustic poison a. Prepare tracheostomy set b. Kerosine (use mineral oil to coat the intestine to prevent absorption) c. Give vinegar to neutralize acid (for muriatic acid ingestion) LEAD POISONING - Destroy RBC functioning - Resulting to hypochromic mycrocytic anemia - Leading to kidney destruction - That leads to accumulation of amonia - Then encephalitis Assessment a. Beginning symptoms of lethargy b. Impulsive and c. As lead increases, severe encephalophaty with seizures and permanent mental retardation Diagnostic Procedure a. Blood Smear b. Abdominal X-ray c. Long bones Management - Remove from source - If higher than 20 mg/dl last management is chelating agent (balance dimmer parol, CAEDTA) less side effects - Binds with lead and excreted slowly via kidney - Side Effects: nephrotoxicity ANOGENITAL Alerts Female - Pseudo menstruation - Slight bleeding related to hormonal changes - Rape - Tearing of forchet - Concerned with child’s care - Wound follow different stages of healing - Identical wound - Report to authorities within 48 hours (barangay captain, bantay bata) - Shape of pubic hair is inverted triangle Male - Check testes (undescended) - Cryptorchidism common in preterms and management is orchidopexy - Warm room and hand - Check for arch of urine - Hydrocele: fluid filled scrotum (translumination reveal a glowing sign) - Phimosis: tight foreskin (balanitis infection of glans penis) - Varicocele: veins in scrotum is increased EPISPADIAS – meatus is located dorsal (above glans penis) HYPOSPADIAS – meatus is located ventral (below glans penis) CHORDEE – fibrous band causing penis to curve downward Renal Disorder Causes Assessment Findings Treatment Nursing Care 1. Nephrotic - Infectious - Anasarca (general - Steroid - Monitor hydration Syndrome body edema) (Prednisone) status (weight - Massive proteinuria - Diuretics (Lasix) everyday with - No hematuria same clothing) - Serum lipid increase - Decrease sodium, - Fatigue normal protein - Normal or low BP - Increase potassium intake (beef broth) 2. AGN - Autoimmune - Primary peripheral - Anti hypertensive - Monitor weight Grp. A beta periorbital edema hydralasine - Monitor BP hemolytic - Moderate proteinuria (appresoline) - Neurologic status streptococcus - Gross hematuria - Hypertensive - Increase iron (smoky urine) encephalopathy - Decrease - Serum potassium (complication potassium increased anemia) - Decrease sodium - Fatigue - Iron infusion - Increase BP BACK - Check for symmetry and flatness Spina bifida Occulta - Failure of posterior laminae of vertebrae to fuse - Signs and Symptoms: dimpling at lower back - Abnormal tuffs of hair Spina bifida Cystica - With sac Types 1. Meningocele – protrusion of CSF and meninges 2. Myelomeningocele – protrusion of CSF, meninges and spinal cord 3. Encephalocele – cranial meningocele or myelomeningocele Common Complication - Common problem is rupture of sac (place wet sterile dressing and place in prone position) - Infection - Urinary and fecal incontinence - Paralysis of lower extremities - Hydrocephalus (CNS complication) - Always check for a wet diaper Treatment - Surgery to prevent infection SCOLIOSIS - Lateral curvature of spine common in school age and adolescent - Uneven hemline - S shape back - When bending 1 hip is higher and 1 shoulder prominent Management 1. Conservative a. Exercise b. Avoid obesity 2. Preventive a. Milwaukee brace worn 23 hours a day 3. Corrective a. Surgery – insertion of Harrington rod (post op do log rolling or move as 1 unit) EXTREMITIES I. Digits a. Syndactyly – webbing of digits (ginger like foot) congenital b. Polydactyly – extra digit c. Olidactyly – lacking digit Amelia – total absence of extremities Pocomelia – absence of distal part of extremities Both are caused by THALIDOMIDE II. Erb-duchennes paralysis/Brachial Plexus injury/Brachial palsy - Birth injury due to lateral and excessive traction during a breech delivery Signs and Symptoms - Inability to abduct arm from shoulder, rotate arm externally and supinate forearm - Absence/asymmetrical moro reflex Management - Abduct from shoulder with elbow flexed III. Congenital Hip Dislocation - The head of femur is outside acetabulum Types 1. Subluxated – most common type 2. Dislocated Signs and Symptoms 1. Shortening of the affected leg 2. Asymmetrical gluteal fold 3. Limited movement (early sign) 4. (+) Ortolani’s sign – clicking sound during abduction 5. When able to walk the child limps (late sign) Management 1. Triple the diaper 2. Carry a stride 3. Frejka Splint 4. Pavlik Harness 5. Hip Spica Cast IV. Talipes - Club foot Types a. Equinos – plantar flexion (horse foot) b. Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior portion of foot is flexed towards the anterior leg c. Varus – foot turns in d. Valgus – foot turns out Common combination is TALIPES EQUINO VARUS and TALIPES CALCANEO VALGUS Assessment - Make a habit of straightening legs and flexing to improve to midline position Management - Corrective shoes (Dennis brown SPLINT) - Spica cast CAST Purpose: - Maintain bone alignment - Prevent muscle spasm - Immobilization - Use open palm - Support with soft pillow and dry naturally Nursing Care to Patient with Cast - Circulation, motion, sensation (neurovascular check) Signs of Circulatory Impairment Blueness or coldness Lack of peripheral pulse Edema not corrected with elevation Pain on the casted extremity Tingling sensation (notify doctor because it is a sign of neurological impairment) - Petaling: making the rough surface of cast smooth - Mark cast with ballpen if there is bleeding CRUTCHES - To maintain balance, support weakened leg - Place body on palm - Do palm exercises (squeeze ball) Different Crutch Gaits 1. Swing Through Procedure: 1. Advance both crutches 2. Lift both feet/swing forward/land feet in front of crutches 3. Advance both crutches 4. Lift both feet/swing forward/land feet in front of crutches 2. Swing To Procedure: 1. Advance both crutches 2. Lift both feet/ swing forward/land feet next to crutches 3. Advance both crutches 4. Lift both feet/ swing forward/land feet next to crutches - 1 and 2 is indicated if weight bearing is not allowed in both lower extremities 3. Three Point Gait - Indicated if weight bearing is not allowed on lower extremities Procedure: 1. Advance left foot and both crutches 2. Advance right foot 3. Advance left foot and both crutches 4. Advance right foot 4. Four Point Gail Procedure 1. Advance right crutch 2. Advance left foot 3. Advance left crutch 4. Advance right foot 5. Two Point Gail Procedure 1. Advance left foot and right crutch 2. Advance right foot and left crutch 3. Advance left foot and right crutch 4. Advance right foot and left crutch - 4 and 5 is indicated if weight bearing is not allowed on both lower extremities Other Crutch-Maneuvering Techniques To Sit Down 1. Grasp the crutches at the hand pieces for control 2. Bend forward slightly while assuming a sitting position 3. Place the affected leg forward to prevent weight-bearing and flexion To Stand Up 1. Move forward to the edge of the chair with the strong leg slightly under the sit 2. Place both crutches in the hand on the side of the affected extremity 3. Push down on the hand piece while raising the body to a standing position To Go Down Stairs 1. Walk forward as far as possible on the step 2. Advance the crutches to the lower step. The weaker leg is advanced first and then the stronger one. In this way the stronger extremity shares the work of raising and lowering the body weight with the patient’s arms. To Go Up Stairs 1. Advance the stronger leg first up to the next step 2. Then advance the crutches and the weaker extremity (Strong leg goes up first and comes down last.) A memory device for the patients is “up with the good, down with the bad.” WALKER - A walker provides more support than a cane or crutches The patient is taught to ambulate with the walker as follows: 1. Patient must hold the walker on the hand grips for stability 2. Lift the walker, placing it in front of you while leaning your body slightly forward 3. Walk into the walker, support your body weight on your hands when advancing your weaker leg permitting partial weight-bearing or non-weight-bearing leg as prescribed 4. Balance yourself on your feet 5. Lift the walker and place it in front of you again. Continue this pattern of walking CANE - A cane is used to help the patient walk with greater balance and support and to relieve pressure on weight-bearing joints by redistributing the weight. Quad canes (four-footed canes.) The cane is held in the hand opposite to the affected extremity Methods of transferring the patient from the bed to a wheelchair a. Weight-bearing transfer from bed to chair. The patient stands up, pivots his back is opposite to the new seat, and sits down b. (Left) Non-weight-bearing transfer from bed to chair. (Right) With legs braced c. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight-bearing transfer, pull-up method Therapeutic Exercises Exercise Description Purpose Action Passive An exercise carried out To retain as much joint Stabilize the proximal by the therapist or the range of motion as joint and support the nurse without assistance possible to maintain distal part. Move the from the patient circulation joint smoothly, slowly, and gently through its full range of motion. Avoid producing pain. Active assistance An exercise carried out To encourage normal Support the distal part, by the patient with the muscle function and encourage the assistance of the patient to take the joint therapist or the nurse actively through its range of motion. Give no more assistance than is necessary to accomplish the action. Short periods of activity should be followed by adequate rest periods. Active An exercise To increase muscle When possible, active accomplished by the strength. exercise should be patient without performed against assistance, activities gravity. The joint is include turning from side moved through full to side and from back to range of motion without abdomen and moving up assistance. (Make sure and down in bed. that the patient does not substitute another joint movement for the one intended.) Resistive An active exercise To provide resistance to The patient moves the carried out by the increase muscle power. joint through its range of patient working against motion while the resistance produced by therapist resists slightly either manual or at first and then with mechanical means. progressively increasing resistance. Sandbags and weights can be used and are applied at the distal point of the involved joint the movement should be performed smoothly. Isometric or muscle Alternately contracting To maintain strength Contract or tighten the setting and relaxing a muscle when a joint is muscle as much as while keeping the part in immobilized possible without moving a fixed position; this the joint, hold for exercise is performed by several seconds, then let the patient go and relax. Breathe deeply. TRACTION - Use to reduce dislocation and immobilize fractures Principles of Traction 1. The client should be in dorsal or supine position 2. For every traction there is always a counter traction 3. Line of pull should be in line with deformity 4. For traction to be effective it must continuous Types Straight Traction - Weight of body serves as counter pull Skin Traction - Applied directly to skin a. Bryant’s traction - Use to immobilize ages below 3 years old - 90O angle with buttoks off bed b. Buck’s extension - Immobilize fracture ages more than 3 years old c. Skeletal - Applied directly to bone d. Halo traction - Immobilize spine Skeletal Traction Nursing responsibility 1. Assess for circulatory and neurologic impairment 2. It can lead to hypertension 3. Be careful in carrying out nursing functions by not moving the weights AUTOIMMUNE SYSTEM Types of immunity a. Passive Natural – maternal antibodies through placenta or breast milk b. Active Natural – contract disease and produce memory cells c. Passive Artificial – receive anti serum with anti bodies from another host (Hepa B) d. Active Artificial – receive vaccination and produce memory cell Immunity from mother (last for 9 – 12 months) - Diptheria - Polio - Pertusis - Tetanus - Measles NEUROMUSCULAR SYSTEM: Reflexes a. Blink reflex – rapid eyelid closure when strong light is shown b. Palmar grasp reflex – solid object is placed on palm and baby grasp object - Purpose: cling to mother for safety (disappear by 6 weeks – 2 months) c. Step in/Walk-in Place Reflex – neonate placed on a vertical position with their face touching a hard surface will take few quick, alternating steps. - Placing Reflex: almost the same with step in place reflex only that you are touching anterior surface of a newborn’s leg. d. Plantar grasp reflex – when an object touches the sole of a newborn’s foot at the base of toes, the toes grasp in the same manner as fingers do (disappear by 8 – 9 months in preparation for walking) e. Tonic-neck-reflex – when newborns lie on their backs, their heads usually turn to one side or the other. The arm and the leg on the side to which the head turns extend, and the opposite arm and leg contract. f. Moro reflex – test for neurological integrity (jarring crib, loud voice) assume a letter C position (disappear by 4 – 5 months) g. Magnet reflex – when there is pressure at the sole of the foot he pushes back against the pressure. h. Crossed extension reflex – when the sole of foot is stimulated by a sharp object, it causes the foot to rise and the other foot extend (test for spinal cord integrity) i. Truck Incurvation reflex – while in prone position and the paravertical area is stimulated, it causes flexion of the trunk and swing his pelvis toward the touch. j. Landau reflex – while prone position and the trunk is being supported, the baby exhibit some muscle tone (test for muscle tone and present by 6 – 9 months) k. Parachute reaction – while on ventral suspension with the sudden change of equilibrium, it causes extension of the hands and legs (present by 6 – 9 months) l. Babinski reflex – when the sole of foot is stimulated by an inverted “J”, it causes fanning of toes (disappear by 2 months but may persist up to 2 years)
"I Scarf sign"